Biodata Format for Nurses - DOC

Document Sample
Biodata Format for Nurses - DOC Powered By Docstoc
					Application Resource Tool

                              Association of periOperative Registered Nurses
                              CONTACT HOUR APPROVAL – Resource Tool
                 NOT AN APPLICATION. PLEASE USE THE WEB-BASED APPLICATION


INSTRUCTIONS: Please use this document as a resource for gathering information and preparing to
apply for contact hours. DO NO USE AS THE APPLICATION. All applications must be submitted
through the web.

Applicant:                                                                                          Chapter #:
(Chapter/Organization Name)                                                                         (if applicable)


_____ Level I: ALL AORN Constituents (ALL Chapters, Specialty Assemblies, or State Councils)
_____ Level II: Health Care Providers (Hospitals, Ambulatory Settings, Clinics) or Local/Regional Nursing Organizations
_____ Level III: Entrepreneurs or National/Specialty Nursing Associations with a primary focus on continuing education
                   for nurses

Title of Activity:
Date of Activity:                                                                   Number of contact hours:


PLANNING COMMITTEE
A minimum of two (2) people must be directly involved in planning and evaluating the educational
activity, including a minimum of ONE (1) registered nurse with a BSN or higher degree in nursing.
Each member of the planning group must represent at least one of the following areas: relevant
content expertise (RCE); target audience (TA); responsibility for adherence to criteria (AC). Please
identify all that apply.

PLANNING COMMITTEE MEMBER #1 - Biographical Data Form must be attached
biodata form
Name, Credentials:
Address:
City, State, Zip:
Telephone:                    Work:                                                  Home:
                              Fax:                                                   Email:

PLANNING COMMITTEE MEMBER #2 - Biographical Data Form must be attached
Name, Credentials:
Address:
City, State, Zip:
Telephone:                    Work:                                                  Home:
                              Fax:                                                   Email:

Key contact person:

                                                                                                                             1
AORN                                  1/09 – Application for Approval of Contact Hours - eff. 1/01/09                 Page
Application Resource Tool

Applicant:                                                                                   Chapter #:
(Chapter/Organization name)                                                                  (if applicable)
Title of Activity:                                                                           Date of Activity:


             BIOGRAPHICAL DATA FORM - Planning Committee Member Only
                     Information for each person must be presented on a copy of this form only.
                   DO NOT ATTACH CVs, RESUMES, OR ANY OTHER ADDITIONAL MATERIAL

Name, Credentials:
Preferred Street Address:
City, State, Zip:
Preferred Telephone/ Contact
Method :
Employer:
Present Position (Title):

Education        Include basic college preparation through highest degree(s) held. Do not list work/degree in
progress.
                                                                                             Major Area          Year Degree
                              Institution Name                               Degree           of Study            Awarded
1
2
3


                                                   PLANNING EXPERTISE

Describe your expertise/experience in planning and ensuring the quality of continuing education activities only:




Planning Committee Member - Conflict of Interest:

AORN is accredited as an approver of continuing nursing education (CNE) by the American Nurses Credentialing
Center‟s Commission on Accreditation. As an accredited approver, AORN must ensure objectivity, and balance, in all
approved activities.

All planners/presenter(s) are required to disclose all relevant financial relationships with any entity with a commercial
interest (e.g. pharmaceutical companies, biomedical device manufactures and or corporations whose products or services
are related to pertinent therapeutic areas).

ANCC/AORN defines “financial relationships” as those relationships in which the individual benefits by receiving:
    salary, royalty, intellectual property rights, consulting fee, honoraria, ownership interest (e.g., stocks, stock
      options, or other ownership interest, excluding diversified mutual funds), or other financial benefit.

                                                                                                                               2
AORN                               1/09 – Application for Approval of Contact Hours - eff. 1/01/09                      Page
Application Resource Tool
        Financial relationships can also include „contracted research‟ where the institution gets the grant and manages
         the funds and the individual is the principal or name investigator on the grant.

Financial benefits are usually associated with roles such as employment, management position, independent contractor
(including contracted research), consulting, speaking and teaching, membership on advisory committees or review
panels, board membership, and other activities from which a fee is received, or expected. ANCC considers relationships
of the person involved in the CNE activity to include financial relationships of a family member.

ANCC/AORN considers financial relationships in any amount occurring within the past 12 months as “relevant” in terms of
creating a conflict of interest.

Presentations must provide a balanced view of therapeutic options. Use of generic names will contribute to this
impartiality.

Planning committee members are responsible for ensuring that all conflict of interest information for
planners/presenter(s) has been resolved and disclosed.

The intent of this disclosure is not to prevent planning committee members/presenter(s) with a significant financial
relationship from participating, but rather to provide the attendees with information for their own judgment.

1. Check ONE of the following two boxes, then proceed as directed.

                  I declare that I do NOT have any affiliation with or financial relationship/interest in a commercial
                  organization that could pose a conflict of interest with the educational content of this program.

                  I have an affiliation or financial relationship/interest which could be perceived as posing a potential conflict
                  of interest with the educational program.
                  If the box above is checked, please answer ALL of the remaining questions.

2. I have significant relationship with the commercial supporter (sponsor) of the session(s).

            Yes               No                Do not know if session is sponsored

3. I, or a member of my family, or partner, have a significant financial interest or other significant relationship with one or
   more companies who manufacture products used in the treatment of perioperative patients (list relationship and
   company below):

            Yes              No

    Relationship                                   Name of Commercial Company (ies)

1   Consultant/Speakers’
    Bureau
2   Employee
3   Stockholder
4   Product Designer
5   Grant/Research Support
6   Large Gift (s)
7   Other Support (specify)


 How was conflict resolved?
______Discussed with other planning committee member and confirm this relationship will not impact program.




                                                                                                                                3
AORN                               1/09 – Application for Approval of Contact Hours - eff. 1/01/09                       Page
Application Resource Tool

Applicant:                                                                                   Chapter #:
(Chapter/Organization Name)                                                                  (if applicable)
Title of Activity:                                                                           Date of Activity:


             BIOGRAPHICAL DATA FORM - Planning Committee Member Only
                     Information for each person must be presented on a copy of this form only.
                   DO NOT ATTACH CVs, RESUMES, OR ANY OTHER ADDITIONAL MATERIAL

Name, Credentials:
Preferred Street Address:
City, State, Zip:
Preferred Telephone/ Contact
Method :
Employer:
Present Position (Title):

Education        Include basic college preparation through highest degree(s) held. Do not list work/degree in
progress.
                                                                                             Major Area          Year Degree
                              Institution Name                               Degree           of Study            Awarded
1
2
3



                                                   PLANNING EXPERTISE

Describe your expertise/experience in planning and ensuring the quality of continuing education activities only:




Planning Committee Member - Conflict of Interest:

AORN is accredited as an approver of continuing nursing education (CNE) by the American Nurses Credentialing
Center‟s Commission on Accreditation. As an accredited approver, AORN must ensure objectivity, and balance, in all
approved activities.

All planners/presenter(s) are required to disclose all relevant financial relationships with any entity with a commercial
interest (e.g. pharmaceutical companies, biomedical device manufactures and or corporations whose products or services
are related to pertinent therapeutic areas).

ANCC/AORN defines “financial relationships” as those relationships in which the individual benefits by receiving:
    salary, royalty, intellectual property rights, consulting fee, honoraria, ownership interest (e.g., stocks, stock
      options, or other ownership interest, excluding diversified mutual funds), or other financial benefit.


                                                                                                                               4
AORN                               1/09 – Application for Approval of Contact Hours - eff. 1/01/09                      Page
Application Resource Tool
        Financial relationships can also include „contracted research‟ where the institution gets the grant and manages
         the funds and the individual is the principal or name investigator on the grant.

Financial benefits are usually associated with roles such as employment, management position, independent contractor
(including contracted research), consulting, speaking and teaching, membership on advisory committees or review
panels, board membership, and other activities from which a fee is received, or expected. ANCC considers relationships
of the person involved in the CNE activity to include financial relationships of a family member.

ANCC/AORN considers financial relationships in any amount occurring within the past 12 months as “relevant” in terms of
creating a conflict of interest.

Presentations must provide a balanced view of therapeutic options. Use of generic names will contribute to this
impartiality.

Planning committee members are responsible for ensuring that all conflict of interest information for
planners/presenter(s) has been resolved and disclosed.

The intent of this disclosure is not to prevent planning committee members/presenter(s) with a significant financial
relationship from participating, but rather to provide the attendees with information for their own judgment.

1. Check ONE of the following two boxes, then proceed as directed.

                  I declare that I do NOT have any affiliation with or financial relationship/interest in a commercial
                  organization that could pose a conflict of interest with the educational content of this program.

                  I have an affiliation or financial relationship/interest which could be perceived as posing a potential conflict
                  of interest with the educational program.
                  If the box above is checked, please answer ALL of the remaining questions.

2. I have significant relationship with the commercial supporter (sponsor) of the session(s).

            Yes               No                Do not know if session is sponsored

3. I, or a member of my family, or partner, have a significant financial interest or other significant relationship with one or
more companies who manufacture products used in the treatment of perioperative patients (list relationship and
company below):

            Yes              No

    Relationship                                   Name of Commercial Company (ies)

1   Consultant/Speakers’
    Bureau
2   Employee
3   Stockholder
4   Product Designer
5   Grant/Research Support
6   Large Gift (s)
7   Other Support (specify)



 How was conflict resolved?
______Discussed with other planning committee member and confirm this COI will not impact program.




                                                                                                                                 5
AORN                               1/09 – Application for Approval of Contact Hours - eff. 1/01/09                       Page
Application Resource Tool
                                          PLANNING CHECKLIST
1) Needs Assessment
       a) How was the need for this activity assessed?
          _____ Needs Assessment
          _____ Survey
          _____ Professional literature
          _____ Discussion with potential learners

    b) Findings of needs assessment __________________________________________________

2) Target Audience The target audience is the group of people to whom the activity is directed.
        a) Describe the target audience for this activity
            _____ Perioperative RNs
            _____ General RN audience
            _____ Health Care Team
                   Other:

3) Physical Facility
       a) Provide name/address of physical facility to be used for this program. – LIVE presentation only.

         Name:
         Address:
         City/State

4) Co-sponsorship
   a) _____ This activity does not have a co-sponsor.
   b) _____ Co-sponsorship of this activity has been provided by : ____________________

   _________________________________________________________________________

5) Presenters/Planning Committee
    a) Planning Expertise

       ANCC requires that all three areas of expertise listed below must be covered by the planning committee
       and the planned speaker. Please list the name of the presenter/planner next to her/his area of expertise
       below.

                      AREA OF EXPERTISE                              NAME: PLANNER/PRESENTER

         Relevant Content Expertise


         Target Audience


         Adherence to Criteria



   b) Conflict of Interest
       i. _____ Biographical Data Forms for each presenter and each planning committee member are
       attached
       ii. _____ Each presenter and each planning committee member has declared on the Biographical Data
       Form if he/she has a conflict of interest.
                                                                                                               6
AORN                          1/09 – Application for Approval of Contact Hours - eff. 1/01/09           Page
Application Resource Tool
       iii. _____ Learners will be informed of presenter‟s/planning committee member‟s declaration of conflict
       of interest by:
       iv. _____ Not applicable - presenters/planning committee members have no conflicts of interest
               _____ Announcement at beginning of activity
               _____ Information provided on advertising
               _____ Information provided on hand-outs
               _____ Signs placed inside or outside of presentation room
               _____ Other:

6) Commercial Support or In-Kind assistance If no, check “a”. If yes, check “b”, “c”, and “d”. (Contact hours
may not be awarded in the exhibit area.)
        a) _____ This activity has no commercial support or in kind assistance
        b) _____ Commercial support (financial support) or in kind assistance for the educational
        component of this program has been provided. You must submit a Written Agreement for
        Commercial Support on page 17 of this application.

          c) _____ Commercial support or in-kind assistance provided by these organizations does not
             influence the objectives or the content of this activity
          d) ______ Nurse planner discussed with commercial entity the need to prevent bias in the content
          e) Learners will be informed about commercial support, in-kind assistance, or off-label use (using a
             product in a way not FDA approved) in the following manner:
              _____ Information provided on advertising materials
              _____ Announcement at beginning of program
              _____ Information on handouts given at start of event
              _____ A sign displayed in the exhibit area
              _____ Other:

7) Evaluation
   a) Check all applicable method(s) of evaluation to be used:
      _____ Evaluation Form (required for all events)
      _____ Pre and/or Post test (optional) (If post-test is used, what is passing score? _________)
      _____ Return Demonstration (optional)
      _____ Other:
   b) Submit a copy of the evaluation tool to be used for this event. It must include, at a minimum, (a)
      purpose/goal; (b) achievement of objectives; (c) teaching effectiveness of each presenter; (d)
      verification of notification of commercial support (CS), In-Kind support (IKS), conflict of interest (COI),
      and/or off-label use (OLU).
   c) For activities that are intended to be offered on an ongoing basis, please identify how the evaluation
      data will be used:
      _____ Not Applicable – this program will not be repeated
      _____ Refine future presentations of this course
      _____ Create new programs
      _____ Discontinue the activity
      _____ Decide whether or not to change faculty
      _____ Decide whether or not to change facility
      _____ Other:
   d) Learner Feedback: Check all that apply or describe how learners will be provided feedback.
      _____ “Questions and Answers” during activity
      _____ Return results of testing
      _____ Provide Certificate
      _____ Follow-up communication
      _____ Other:
   e) Purpose/Goal
      _____ A Purpose/Goal statement has been included on the Evaluation Form. This statement describes
      how this activity will enrich the nurse's contributions to quality health care or what is hoped the outcome
      of the activity will be. The purpose/goal is a broad statement.
                                                                                                                 7
AORN                          1/09 – Application for Approval of Contact Hours - eff. 1/01/09            Page
Application Resource Tool

8) Verification of Participation and Successful Completion Applicant must identify criteria for verifying
   participation and successful completion of the learning activity and how learners will be informed of these
   criteria.
   a) Identify method for verifying participation
                 Roll call                                   Sign-in sheets
                 Self-reported attendance                    Return of evaluation forms
   b) Identify method(s) to be used to identify successful completion
                 Attendance at session(s) for an identified percentage of time. Percent:
                 Submission of a written post test
                 Return demonstration
                 Self-reported level of achievement of objectives (completion of Evaluation)
   c) Identify method(s) to be used to inform learners of criteria
                 Brochure
                 Announcement during each introduction (beginning of each presentation)
   d) Post-Activity Report
                  A Post-Activity Report will be submitted within 30 days of the activity. Required information
        must include the total number of participants, the total number of contact hours awarded, a summary of
        evaluations, and a sample of the Certificate of Attendance distributed at the program. For repeat
        activities, please include how this activity will be changed based on evaluations.

9) Disclosure of Previous Program Denial(s) For all applications acted upon, the applicant must disclose
   any previous denials of the program by other ANCC accredited approver units. If this program has been
   previously denied, the peer reviewers and administrators of AORN‟s Approval Unit will consider the
   reasons for denial and decide if these can be resolved.
    a) Identify previous denial(s)
        ______ There are no previous denial(s) for this program
        ______ This program was previously denied CE approval by the following ANCC accredited
                   approver units: _____________________________________________________
                                   _____________________________________________________
                                   _____________________________________________________

10) Recordkeeping and Storage System Records for each educational activity must be kept for six (6)
   years and must include the following essential information:
    The complete application form and all supporting documentation, including
      o Biographical Data Forms for each Planning Committee Member and for each Presenter,
      o Planning Checklist,
      o Commercial Support Agreement
      o Activity Documentation Form,
      o Evaluation Form, and
      o Certificate of Attendance;
    Brochures/activity announcements/flyers;
    Post Activity Report, including total number of attendees, summary of evaluations, and Certificate of
      Attendance.
    All correspondence regarding the approval process directly affecting the application approval must also
      be kept.

   Additionally, an applicant must be able to determine within its own setting how confidential records are
   maintained and handled and which personnel have access to the records. Mechanisms must be in place
   for systematic, easy retrieval, retention, and disposal of information by authorized individuals.

   a) _____ Confidential and complete records of each application will be maintained for six (6) years and
      will be filed in a secured manner with a representative of the Applicant.

11) Contact Hour Calculation for Live Presentations Contact hour calculation is based on 60 minutes.
   Therefore, 60 minutes of education content time is equal to one (1) contact hour. This does not include
                                                                                                              8
AORN                         1/09 – Application for Approval of Contact Hours - eff. 1/01/09           Page
Application Resource Tool
      introductions or breaks/meals. A minimum of one-half (.5) contact hour must be awarded. Add the total
      number of minutes of education content and divided by 60 to determine contact hours.

      Live presentations involve participant attendance. It is distinguishable by the fact that the pace of the activity is
      determined by the group who plans and schedules the activity. Examples include, but are not limited to, conventions,
      courses, seminars, workshops, and lecture series. Knowledge and use of adult learning principles should be reflected
      in all aspects of the objectives, content, and teaching methods.


12)     Contact Hour Calculation for Independent Studies – this section N/A for LIVE presentations

      Independent study programs are designed for completion by learners, independently, at the learner’s own
      pace, and at a time of the learner’s choice. The applicant designs the educational program, and, through a
      pilot study or other defensible mechanism, determines the number of contact hours to be awarded.
      Examples: viewing videotapes or listening to audiotapes and completing post test questions; accessing
      computer on-line activities; reading selected articles and completing post test questions.

                                            CONTACT HOUR CALCULATION

The applicant must demonstrate the rationale for determining the number of contact hours to be awarded.
Examples of methods to determine contact hours include pilot testing or word count formulas, such as the
Mergener formula.

Suggestions for Pilot-Testing
 In order to identify potential problems and provide evidence of the effectiveness of a program, a pilot-test is
conducted with a group of representative learners from the target audience before finalizing the education activity
for distribution and use. A pilot test also documents the time required for the learner to achieve the objectives.

The number of RN pilot-testers varies depending on the purpose and design of the activity as well as the size of
the target audience. The entire learning package should be completed by the pilot-testers as if they were
completing it for continuing education credit, including post test (self assessments), return demonstrations or other
requirements, and evaluations. Feedback from the pilot-testers enables the planning committee to improve the
activity prior to making it available for continuing education credit. Conducted prior to implementation of the activity
the pilot-test provides evidence of the:

          a. Effectiveness of the design and the teaching/learning materials
          b. Time required to complete the activity.
          c. Basis for determining the number of contact hours to be awarded for successful completion of the
             activity. The contact hours must reflect the documented time required by the pilot-test group to
             achieve the stated objectives. This may be an average of all time required or an average time of the
             majority of pilot-testers after discarding very short or very long time frames.

Upon completion of the pilot-test, the planners and content specialist(s) should carefully review the
feedback/findings of the group to note if changes should be adopted before the activity is finalized or
completed. Describe what changes were made based on this evaluation.

Mergener Formula – example

Place number of words in article on Column B. Place number of questions in test in column B.
Determine difficulty of material (depends on audience): Very ease = 1; Somewhat east = 2; Moderate = 3;
Difficult = 4; Very difficult = 5

                  Constants
                            A                      B
                  Number of words:              3,774
                  Number of questions              16
                                                                                                                         9
AORN                              1/09 – Application for Approval of Contact Hours - eff. 1/01/09                 Page
Application Resource Tool
               Difficulty of material           2.5


         Mergener Formula: [-22.3 + (0.00209 x number of words) + (2.78 x number of questions) + (15.5 x
         difficulty of material)] = subtotal
         Subtotal x 0.9 = total minutes

         Subtotal = 68.81766
         Total Minutes = 61.93589
         Contact Hours = Total minutes/60
         Contact Hours = 1.0
         (Always round down for contact hour calculation)

   See also: Mergener, MA, “A Preliminary Study to Determine the Amount of Continuing Education Credit to
   Award Home Study Programs,” American Journal of Pharmaceutical Education, Vol. 55, Fall 1991 (263-266).


   a) Describe how the effectiveness of the independent study was evaluated, the results of the evaluation,
      and the changes made based on the evaluation:


   b) What method was used for calculating the contact hours? (Check the best description(s) that applies)
      _____ Pilot Study *
      _____ Peer Review
      _____ Historical Data
      _____ Complexity of content and data
      _____ Determination of number of words in article and level of complexity
      _____ Other

   c) Provide supportive documentation of the rationale used to determine the number of contact hours to be
      awarded:




   d) Include a copy of your teaching tool.
   e) You must send a copy of your finished article for review. Advertising may not be included on
      article/study pages, and you must identify any conflict of interest.


   *Members of the target audience reviewed and identified the number of minutes it took them to complete the activity
   and an average was taken to determine contact hours.




                                                                                                                         10
AORN                           1/09 – Application for Approval of Contact Hours - eff. 1/01/09                  Page
Application Resource Tool
13) Marketing / Promotional Materials A copy of the wording used in all announcements for this event
    MUST be included with your application. (This may be a draft of what you intend to publish).

   Promotional materials/announcements should contain the chapter/group name, chapter # (if applicable),
   the day, date, time, and location of the event, the title of the event and the pending contact hours.
   Additional information could include speaker name, contact person/information, purpose/goal, any
   commercial support, etc.

   NOTE: Only AORN chapters may use the AORN logo; to appear only on chapter letterhead, chapter
   websites, educational certificates and chapter newsletters.

   ANCC REQUIREMENT: The following statement MUST appear in this format on ALL
   marketing/promotional materials (including E-mail notifications) PRIOR to final approval of activity:

   This activity has been submitted to the Association of periOperative Registered Nurses, Inc. for approval to
   award contact hours. The Association of periOperative Registered Nurses, Inc. is accredited as an
   approver of continuing nursing education by the American Nurses Credentialing Center‟s Commission on
   Accreditation.

   Activities that are approved by AORN are recognized as continuing education for registered nurses. This
   recognition does not imply that AORN or the ANCC Commission on Accreditation approves or endorses
   any product included in the presentation.


   After the activity has been approved, all promotional materials for FUTURE presentations of the same
   approved program must contain the following in this format:

  This continuing nursing education activity was approved by the Association of periOperative Registered
   Nurses, Inc., an accredited approver by the American Nurses Credentialing Center's Commission on
   Accreditation.

  Activities that are approved by AORN are recognized as continuing education for registered nurses. This
   recognition does not imply that AORN or the ANCC Commission on Accreditation approves or endorses
   any product included in the presentation.



   Please identify the method used to inform potential participants of this program (submit a sample of the
wording you will use):
   a) _____ Flyer / brochure
   b) _____ Chapter Newsletter
   c) _____ Memo / letter
   d) _____ Meeting notice
   e) _____ E-mail
   f) _____ Web site
   g) Other




                                                                                                               11
AORN                         1/09 – Application for Approval of Contact Hours - eff. 1/01/09            Page
Application Resource Tool

Applicant:                                                                                 Chapter #:
(Chapter/Organization Name)                                                                (if applicable)
Title of Activity:                                                                         Date of Activity:




                              BIOGRAPHICAL DATA FORM – Presenter Only
                         Information for each person must be presented on a copy of this form only.
                       DO NOT ATTACH CVs, RESUMES, OR ANY OTHER ADDITIONAL MATERIAL

Name, Credentials:
Preferred Street Address:
City, State, Zip:
Preferred Telephone/ Contact
Method :
Employer:
Present Position (Title):




                                                 PRESENTER EXPERTISE

Presenter: Describe your expertise in/experience presenting this topic only:

Presenter Conflict of Interest

AORN is accredited as an approver of continuing nursing education (CNE) by the American Nurses Credentialing
Center‟s Commission on Accreditation. As an accredited approver, AORN must ensure objectivity, and balance, in all
approved activities.

All planners/presenter(s) are required to disclose all relevant financial relationships with any entity with a commercial
interest (e.g. pharmaceutical companies, biomedical device manufactures and or corporations whose products or services
are related to pertinent therapeutic areas).

ANCC/AORN defines “financial relationships” as those relationships in which the individual benefits by receiving:
    salary, royalty, intellectual property rights, consulting fee, honoraria, ownership interest (e.g., stocks, stock
      options, or other ownership interest, excluding diversified mutual funds), or other financial benefit.
    Financial relationships can also include „contracted research‟ where the institution gets the grant and manages
      the funds and the individual is the principal or name investigator on the grant.

Financial benefits are usually associated with roles such as employment, management position, independent contractor
(including contracted research), consulting, speaking and teaching, membership on advisory committees or review
panels, board membership, and other activities from which a fee is received, or expected. ANCC considers relationships
of the person involved in the CNE activity to include financial relationships of a family member.

ANCC/AORN considers financial relationships in any amount occurring within the past 12 months as “relevant” in terms of
creating a conflict of interest.

Presentations must provide a balanced view of therapeutic options. Use of generic names will contribute to this
impartiality.

Planning committee members are responsible for ensuring that all conflict of interest information for
planners/presenter(s) has been resolved and disclosed.
                                                                                                                         12
AORN                              1/09 – Application for Approval of Contact Hours - eff. 1/01/09                 Page
Application Resource Tool
The intent of this disclosure is not to prevent planning committee members/presenter(s) with a significant financial
relationship from participating, but rather to provide the attendees with information for their own judgment.

1. Check ONE of the following two boxes, then proceed as directed.

                  I declare that I do NOT have any affiliation with or financial relationship/interest in a commercial
                  organization that could pose a conflict of interest with the educational content of this program.

                  I have an affiliation or financial relationship/interest which could be perceived as posing a potential conflict
                  of interest with the educational program.
                  If the box above is checked, please answer ALL of the remaining questions.

4. I have significant relationship with the commercial supporter (sponsor) of the session(s).

            Yes               No                Do not know if session is sponsored

5. I, or a member of my family, or partner, have a significant financial interest or other significant relationship with one or
   more companies who manufacture products used in the treatment of perioperative patients (list relationship and
   company below):

            Yes              No

    Relationship                                   Name of Commercial Company (ies)

1   Consultant/Speakers’
    Bureau
2   Employee
3   Stockholder
4   Product Designer
5   Grant/Research Support
6   Large Gift (s)
7   Other Support (specify)


How was conflict resolved?
______Discussed with planning committee member and confirm this COI will not impact program.




                                                                                                                                13
AORN                               1/09 – Application for Approval of Contact Hours - eff. 1/01/09                       Page
Application Resource Tool
                               ACTIVITY DOCUMENTATION FORM (ADF)
                  Please reference the Directions for assistance in writing objectives and content.

Applicant:                                                                                               Chapter #:
(Chapter/Organization Name)                                                                              (if applicable)


Title of Activity:

Date of Activity:

In the spaces provided    below, write your educational learning objectives for this program in measurable terms. Number
each objective, include   all content for each objective presented in a topic outline form, include the timeframe allotted for
each objective (do not    include time allotted for introductions, breaks/meals), list the presenter(s), and list the teaching
strategies to be used.    For assistance and tips in writing educational learning objectives, refer to the Directions
document.

Type in all 5 columns across the page for your first objective. Tab between columns. When you‟ve finished typing in your
teaching strategies in the last column, hit the “tab” key to go to the next row, where you can then type in all 5
                   nd
columns for the 2 objective, etc.

                                                                                                                      Teaching
       Objectives                     Content (topics)                  Timeframe                   Presenter         Strategies
 List the educational          Provide an outline of the                Provide a definite          List the          List the
 objectives in the space       content presented and indicate           timeframe                   presenter         teaching
 below.                        to which objective the content           expressed in                name/subje        strategies to
                               is related in the space below.           minutes for each            ct matter         be used for
                                                                        objective or                expert for        each objective
                                                                        content area.               each              or content
                                                                        (For Independent            objective or      area in the
                                                                        Study, list total           content area      space below.
                                                                        minutes.)                   in the space
                                                                                                    below.
 1.




                                                                                                                                    14
AORN                              1/09 – Application for Approval of Contact Hours - eff. 1/01/09                            Page
Application Resource Tool
                                              EVALUATION FORM


Applicant:                                                                                          Chapter #:
(Chapter/Organization Name)                                                                         (if applicable)


Title of Activity:

Date of Activity:

Learner's achievement of each objective. Rate each on a scale of 1 = low, 5 = high

Objective 1:
                                          1                 2                 3                 4                     5

Objective 2:
                                          1                 2                 3                 4                     5

Objective 3:
                                          1                 2                 3                 4                     5

Objective 4:
                                          1                 2                 3                 4                     5

Objective 5:
                                          1                 2                 3                 4                     5

Objective 6:
                                          1                 2                 3                 4                     5

Purpose/Goal of this activity:

Relationship of objectives to overall
Purpose/Goal of activity              1                           2                  3                  4                 5

Presenter Name:
Expertise of presenter                 1                          2                  3                  4                 5
Appropriateness of teaching strategies 1                          2                  3                  4                 5




                                                                                                                                 15
AORN                          1/09 – Application for Approval of Contact Hours - eff. 1/01/09                             Page
Application Resource Tool
                                       EVALUATION FORM - page 2


Were you notified of any conflict of interest (COI), off-label use (OLU), commercial support
(CS), and/or in-kind support (IKS) for the education component of this program?
_____ N/A – not applicable for any of the above
       Yes – written notification _____ COI, ___OLU, _____CS, _____IKS
       Yes – verbal notification _____ COI, ___OLU, _____CS, _____IKS
        No – But the following was present__________


Was there product promotion or commercial bias during the education content? For
commercial bias to have taken place, a specific product’s name must be promoted. If products
are referred to in generic terms, that is not commercial bias.

_____ No

_____ Yes (please explain:                                                                    )



Will the information you gained from attending this program change your practice?
_____ Yes (please explain:                                                                    )

_____ No (please explain:                                                                     )


Additional comments or suggestions




                                                                                                     16
AORN                        1/09 – Application for Approval of Contact Hours - eff. 1/01/09   Page
Application Resource Tool

                CERTIFICATE OF ATTENDANCE

                              Applicant (Chapter/Organization Name, Chapter #)



                                                    CERTIFIES



                                   Signature of Participant (Not Valid Until Signed)


                                                HAS ATTENDED




                                                 Title of Activity




                                                 Contact Hours



                 Date of Activity                                                    City and State


This continuing nursing education activity was approved by the Association of periOperative
Registered Nurses, Inc., an accredited approver by the American Nurses Credentialing Center's
Commission on Accreditation.

AORN recognized this activity as continuing education for registered nurses. This recognition did not
imply that AORN or the ANCC Commission on Accreditation approved or endorsed any product
included in the presentation.




                                                Contact Person

                                                      Address

                                                 City, State, Zip

                                                                                                             17
AORN                        1/09 – Application for Approval of Contact Hours - eff. 1/01/09           Page
Application Resource Tool

                        Written Agreement for Commercial Support
                       AORN Continuing Education Approval Process
                        Written Agreement for Commercial Support

ANCC defines “commercial support” as financial, or in-kind, contributions given by a commercial interest, which
is used to pay all or part of the costs of a CNE activity.


Applicant: ___________________________________________________________

Title of Activity: ______________________________________________________

Activity Date: ________________________________________________________

Source of Commercial Support: __________________________________________




                                      Terms, Conditions, and Purposes



Independence

   1. This activity is for scientific and educational purposes only and will not promote any specific proprietary
      business interest of the Commercial Interest.
   2. The Applicant is responsible for all decisions regarding the components of the education activity (CNE
      needs, educational objectives, selection and presentation of content, selection of all persons and
      organizations that will be in a position to control the content of the CNE, and selection of educational
      methods).

Appropriate Use of Commercial Support

   3. The Applicant will make all decisions regarding the disposition and disbursement of funds from the
      Commercial Interest.
   4. The Commercial Interest will not require the Applicant to accept advice concerning the components of
      the education activity as a condition of the grant.
   5. All commercial support associated with this activity will be given with the full knowledge and approval of
      the Applicant. No other payments shall be given to the nurse planner, planning committee members,
      teachers or authors, joint sponsor, or any other involved with the supported activity.

Commercial Promotion

   6. Product-promotion material or product-specific advertisement of any type is prohibited in or during the
      continuing nursing education. Promotional materials cannot be displayed or distributed in the education
      space immediately before, during or after a nursing continuing education activity.
   7. Commercial interests may not engage in sales or promotional activities while in the space or place of
      the continuing nursing education activity.

(page 1 of 2)

                                                                                                                 18
AORN                         1/09 – Application for Approval of Contact Hours - eff. 1/01/09              Page
Application Resource Tool
(Written Agreement for Commercial Support: page 2 of 2)


Disclosure

   8. The Applicant will ensure that the source of support from the Commercial Interest, either direct or in-
      kind, is disclosed to the participants in program brochures, handouts, and other program materials,
      and/or announced at the time of the activity.
   9. This disclosure will not include the use of a trade name or a product-group message. The
      acknowledgment of commercial support may state the name, mission of the company or institution and
      may include corporate logos and slogans, if they are not product promotional in nature.


   The Commercial Interest and the Applicant agree to abide by the requirements of the ANCC COA
   Standards for Disclosure and Commercial Support for continuing nursing education.




                                    Agreed by Authorized Representatives



Commercial Interest                                    Applicant



________________________                               __________________________
Name of Commercial Interest                            Name of Applicant


__________________________                             __________________________
Signature and date                                     Signature and date


__________________________                             __________________________
Print Name                                             Print Name


_________________________                              _________________________
Title                                                  Title




                                                                                                             19
AORN                        1/09 – Application for Approval of Contact Hours - eff. 1/01/09           Page
Application Resource Tool

                                           POST ACTIVITY REPORT

The Post Activity Report must be submitted within 30 days after each event date. This report should include the following:

       Total number of attendees only – do not provide names/addresses
       Total number of contact hours awarded. See below
       SUMMARY of evaluations. Use the form below to provide your totals for each section.
       A sample copy of the final approved Certificate of Attendance distributed to each participant.

Applicant:                                                                                             Chapter #:
(Chapter/Organization Name)                                                                            (if applicable)


Title of Activity:

Date of Activity:

1 - This program was approved for                         contact hours

2 - Total number of participants:

3 - Total number of contact hours awarded:
(contact hours APPROVED multiplied by number of participants equals contact hours AWARDED)

                                          Program Evaluations Summary

Learner's achievement of each objective. Rate each on a scale of 1 = low, 5 = high

Objective 1:
    Totals                                   1                 2                 3                 4                     5

Objective 2:
    Totals                                   1                 2                 3                 4                     5

Objective 3:
    Totals                                   1                 2                 3                 4                     5

Objective 4:
    Totals                                   1                 2                 3                 4                     5

Objective 5:
    Totals                                   1                 2                 3                 4                     5

Objective 6:
    Totals                                   1                 2                 3                 4                     5

                                                                                                                                    20
AORN                             1/09 – Application for Approval of Contact Hours - eff. 1/01/09                             Page
Application Resource Tool
                                      Post Activity Report – Page 2

Purpose/Goal of this activity:

Relationship of objectives to overall
Purpose/Goal of activity              1                         2                  3          4   5

Presenter Name:
Expertise of presenter                 1                        2                  3          4   5
Appropriateness of teaching strategies 1                        2                  3          4   5

Were you notified of any conflict of interest (COI), off-label use (OLU), commercial support
(CS), and/or in-kind support (IKS) for the education component of this program?
_____ N/A – not applicable for any of the above
       Yes – written notification _____ COI, ___OLU, _____CS, _____IKS
       Yes – verbal notification _____ COI, ___OLU, _____CS, _____IKS
        No – But the following was present__________

Was there product promotion or commercial bias during the education content? For
commercial bias to have taken place, a specific product’s name must be promoted. If products
are referred to in generic terms, that is not commercial bias.

_____ No

_____ Yes (please explain:                                                                        )


Will the information you gained from attending this program change your practice?
_____ Yes (please explain:                                                                        )

_____ No (please explain:                                                                         )


***Attach a copy of the approved Certificate of Attendance distributed to each participant.

Additional comments or suggestions




                                                                                                         21
AORN                        1/09 – Application for Approval of Contact Hours - eff. 1/01/09       Page

				
DOCUMENT INFO
Description: Biodata Format for Nurses document sample